Острый тонзиллофарингит (ОТФ) является одним из самых распространенных заболеваний, обусловливающих первичное обращение пациентов за медицинской помощью. В клинической практике дифференциальная диагностика стрептококкового и вирусного фарингита основывается на клинической картине и экспресс-диагностике. При ассоциации фарингита с b-гемолитическим стрептококком группы А наиболее характерным является наличие фебрильной температуры, болей в горле, налетов на миндалинах и передней шейной лимфаденопатии, в то время как вирусный фарингит чаще сочетается с явлениями конъюнктивита, ринита, кашля и диареи. При стрептококковом фарингите показана антибактериальная терапия для профилактики возможных грозных осложнений (в том числе острой ревматической лихорадки и гломерулонефрита), а при вирусном – симптоматическое лечение и обильное питье. Кроме того, ОТФ может присутствовать в клинической картине инфекционного мононуклеоза, острого ретровирусного синдрома при первичном инфицировании ВИЧ и болезни Кавасаки, дифтерии зева и заболеваниях крови. Гнойные инфекции, включающие синдром Лемьера, ангину Людвига, паратонзиллит, парафарингит и ретрофарингеальный абсцесс, также должны рассматриваться в дифференциальной диагностике ОТФ.
Acute tonsillopharyngitis (ATP) is one of the most common diseases that makes patients to search for primary medical care. In clinical practice, the differential diagnosis of streptococcal and viral pharyngitis is based on clinical manifestations along with express diagnostics. In pharyngitis caused by group A b-hemolytic streptococcus, febrile temperature, sore throat, plaque on the tonsils and lymphadenopathy in the anterior part of the neck are most characteristic signs and symptoms, while viral pharyngitis is typically associated with conjunctivitis, rhinitis, cough and diarrhea. In streptococcal pharyngitis, antibacterial therapy is indicated to prevent potential severe complications (including acute rheumatic fever and glomerulonephritis) while in viral pharyngitis – symptomatic treatment and plenty of drinking. In addition, ATP may be a symptom of infectious mononucleosis, acute retroviral syndrome in primary HIV infection and Kawasaki disease, pharyngeal diphtheria and hematological diseases. Purulent infections, including Lemierre's syndrome, Ludwig's angina, paratonsillitis, parapharyngitis, and retropharyngeal abscess, should also be considered in the differential diagnosis of ATP.
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2. Ebell MH, Smith MA, Barry HC et al. The rational clinical examination. Does this patient have strep throat? JAMA 2000; 284 (22): 2912–8. DOI: 10.1001/jama.284.22.2912
3. Hildreth AF, Takhar S, Clark MA, Hatten B. Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department. Emerg Med Pract 2015; 17 (9): 1–16; quiz 16–7.
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9. Pfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A streptococcal pharyngitis. Pediatrics 2008; 121 (2): 229–34. DOI: 10.1542/peds.2007-0484
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16. Shulman ST, Bisno AL, Clegg HW et al; Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55 (10): e86–102. DOI: 10.1093/cid/cis629
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18. Tanz RR, Gerber MA, Rippe J et al. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics 2009; 123 (2): 437–44. DOI: 10.1542/peds.2008-0488
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________________________________________________
1. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010; 26: 1–31.
2. Ebell MH, Smith MA, Barry HC et al. The rational clinical examination. Does this patient have strep throat? JAMA 2000; 284 (22): 2912–8. DOI: 10.1001/jama.284.22.2912
3. Hildreth AF, Takhar S, Clark MA, Hatten B. Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department. Emerg Med Pract 2015; 17 (9): 1–16; quiz 16–7.
4. Polyakov D.P., Karneeva O.V., Ryazantsev S.V. and others. Acute tonsillopharyngitis. Clinical Guidelines of the National Association of Otorhinolaryngologists, 2016 (in Russian).
5. Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med 2011; 364 (7): 648–55. DOI: 10.1056/NEJMcp1009126
6. ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, Galeone C et al. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012; 18 (Suppl. 1): 1–28. DOI: 10.1111/j.1469-0691.2012.03766.x
7. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997–2010. JAMA Intern Med 2014; 174 (1): 138–40. DOI: 10.1001/jamainternmed.2013.11673
8. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics 2010; 126 (3): e557–64. DOI: 10.1542/peds.2009-2648
9. Pfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A streptococcal pharyngitis. Pediatrics 2008; 121 (2): 229–34. DOI: 10.1542/peds.2007-0484
10. Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician 2009; 79 (5): 383–90.
11. Bisno AL. Acute pharyngitis. N Engl J Med 2001; 344 (3): 205–11. DOI: 10.1056/NEJM200101183440308
12. Kriukov A.I., Kunel'skaia N.L., Turovskii A.B. Streptokokkovye zabolevaniia glotki. RMZh. 2006; 14 (27): 5–9 (in Russian).
13. Centor RM, Witherspoon JM, Dalton HP et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981; 1 (3): 239–46. DOI: 10.1177/0272989X8100100304
14. McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998; 158 (1): 75–83.
15. McIsaac WJ, Kellner JD, Aufricht P et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004; 291 (13): 1587–95. DOI: 10.1001/jama.291.13.1587
16. Shulman ST, Bisno AL, Clegg HW et al; Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55 (10): e86–102. DOI: 10.1093/cid/cis629
17. Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR; American Academy of Family Physicians; American College of Physicians-American Society of Internal Medicine; Centers for Disease Control. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med 2001; 134 (6): 506–8. DOI: 10.7326/0003-4819-134-6-200103200-00018
18. Tanz RR, Gerber MA, Rippe J et al. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics 2009; 123 (2): 437–44. DOI: 10.1542/peds.2008-0488
19. Cohen JF, Chalumeau M, Levy C et al. Effect of clinical spectrum, inoculum size and physician characteristics on sensitivity of a rapid antigen detection test for group A streptococcal pharyngitis. Eur J Clin Microbiol Infect Dis 2013; 32 (6): 787–93. DOI: 10.1007/s10096-012-1809-1
20. ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, Galeone C et al. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012; 18 (Suppl. 1): 1–28. DOI: 10.1111/j.1469-0691.2012.03766.x
21. Otvagin I.V., Sokolov N.S. Diagnostika infektsii, vyzvannykh streptokokkami gruppy A. Klinicheskaia mikrobiologiia i antimikrobnaia khimioterapiia. 2011; 3 (13): 223–30 (in Russian).
22. Chapin KC, Blake P, Wilson CD. Performance characteristics and utilization of rapid antigen test, DNA probe, and culture for detection of group a streptococci in an acute care clinic. J Clin Microbiol 2002; 40 (11): 4207–10. DOI: 10.1128/jcm.40.11.4207-4210.2002
23. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2006; 4: CD000023. DOI: 10.1002/14651858.CD000023.pub3
24. Gottlieb M, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. J Emerg Med 2018; 54 (5): 619–29. DOI: 10.1016/j.jemermed.2018.01.031
25. Schachtel BP, Fillingim JM, Thoden WR et al. Sore throat pain in the evaluation of mild analgesics. Clin Pharmacol Ther 1988; 44 (6): 704–11. DOI: 10.1038/clpt.1988.215
26. Chrubasik S, Beime B, Magora F. Efficacy of a benzocaine lozenge in the treatment of uncomplicated sore throat. Eur Arch Otorhinolaryngol 2012; 269 (2): 571–7. DOI: 10.1007/s00405-011-1802-9
27. Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ 2017; 358: j3887. DOI: 10.1136/bmj.j3887
28. Sato S, Kuratomi Y, Inokuchi A. Pathological characteristics of the epiglottis relevant to acute epiglottitis. Auris Nasus Larynx 2012; 39 (5): 507–11. DOI: 10.1016/j.anl.2011.10.015
29. Savenkova M., Balyasinskaya G., Bychkov V. et al. Acute epiglottitis in children (etiopathogenesis, diagnosis, treatment). Curr Pediatrics 2008; 7 (5): 91–7 (in Russian).
30. Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol 2008; 122 (8): 818–23. DOI: 10.1017/S0022215107000473
31. Cherry JD. Epiglottitis (supraglottitis). In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases, 6th. Philadelphia: Saunders, 2009; р. 244.
32. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am 2008; 41 (3): 551–66, ix. DOI: 10.1016/j.otc.2008.01.012
33. Nagovitsyna E.B. Modern approaches to diagnostics and treatment of Epstein–Barr virus infectious mononucleosis. Far East Medical Journal. 2016; 3: 40–5 (in Russian).
34. Ebell MH, Call M, Shinholser J, Gardner J. Does This Patient Have Infectious Mononucleosis? The Rational Clinical Examination Systematic Review. JAMA 2016; 315 (14): 1502–9. DOI: 10.1001/jama.2016.2111
35. Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med 2010; 362 (21): 1993–2000. DOI: 10.1056/NEJMcp1001116
36. Bartlett A, Williams R, Hilton M. Splenic rupture in infectious mononucleosis: A systematic review of published case reports. Injury 2016; 47 (3): 531–8. DOI: 10.1016/j.injury.2015.10.071
37. Lvov N.D., Melnichenko A.V., Panyukova E.M., Shestakova I.V. Infectious mononucleosis. Clinical guidelines. National Scientific Society of Infectious Diseases, 2014. (in Russian).
38. Schwartzkopf J. Infectious mononucleosis. JAAPA 2018; 31 (11): 52–3. DOI: 10.1097/01.JAA.0000546488.73851.dd
39. Thompson SK, Doerr TD, Hengerer AS. Infectious mononucleosis and corticosteroids: management practices and outcomes. Arch Otolaryngol Head Neck Surg 2005; 131 (10): 900–4. DOI: 10.1001/archotol.131.10.900
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Авторы
А.Л. Гусева*1, Ю.В. Левина1, М.Л. Дербенева2
1 ФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия;
2 ГБУЗ «Городская клиническая больница №1 им. Н.И. Пирогова» Департамента здравоохранения г. Москвы, Москва, Россия
*alexandra.guseva@gmail.com
________________________________________________
Aleksandra L. Guseva*1, Iuliia V. Levina1, Mariia L. Derbeneva2
1 Pirogov Russian National Research Medical University, Moscow, Russia;
2 Pirogov City Clinical Hospital №1, Moscow, Russia
*alexandra.guseva@gmail.com